APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
73480
\n application will not be considered complete unless: All lines of the application have been completed in full; A check or money order for $70.00 made payable to the City of Chicago is submitted as payment of the application fee; Please note: The application fee shall be waived for any person holding a valid, current disabled veterans plate. 7* Disability must be permanent as evidenced by a copy of your valid disabled placard and/or current vehicle registration
submitted at the time of application; L7» Proof of residency, in the form of a copy of your drivers license, state identification, or utility bills are submitted at the time of application.
Completed application forms may be returned to: the office of your alderman, any City of Chicago Department of Revenue facility, or via mail at P.O. Box 803100, Chicago, IL 60680-3100, ATTN: Disabled Permitting Section. A $25.00 maintenance fee will be billed to you annually, Should you have questions cr concerns, please call our permit processing division at 312-744-PARK (7275).
1. Date of Birth
MO _ DAY
0 I 7-
YEAR
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2. State Identification Number
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3. Drivers License Number
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Ml First Name
4. Applicant Last Name
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5. Home Address (primary residence)
STREET NUMBER DIR. STREET NAME
ZIP CODE
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6. Address where signs will be posted
STREET NUMBER
STREET NAME
, WARD NUMBER
7. Phone Numbers
Home
Business
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•i 7
8. Current Permanent Disabled Placard Number
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Registered to
Relationship to Applicant
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9. Current License Plate Number
4 GG /
Registered to
City Sticker No.
Relationship to Applicant
"Kijana Sefe
n7^M3/ L'ncoln Ave ^77j
? rnW^ typical Center
(fo.pescftption of Medical Condition and Disability /
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